Foot Deformities

Foot deformities in children include congenital or acquired malformations of the feet. Two common examples are talipes equinovarus, commonly known as clubfoot, and metatarsus adductus, also called metatarsus varus. Depending on their etiology, foot deformities can be self-limiting or may require surgical correction. Early detection and recognition are crucial for proper treatment.

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Clubfoot (Talipes Equinovarus)

Definition

Clubfoot, also called talipes equinovarus, is a complex condition with a plantar flexed foot (equinus), adductus of the forefoot, and an inversion deformity of the heel (varus).

Epidemiology

  • Strong familial tendency
  • 1–3 per 1,000 live births:
    • Highest in Polynesian population: 7 per 1,000 live births
    • Lowest in Asian population: 0.6 per 1,000 live births
  • Male-to-female ratio: 2:1

Etiology

Etiology is debated, as the majority of infants with clubfoot have no identifiable syndromic, genetic, or extrinsic cause.

  • Positional, or postural, clubfoot: normal foot held in deforming position during gestation; usually easily correctable
  • Congenital: most common type; usually treated with casting and bracing
  • Syndromic: clubfoot associated with other congenital syndromes
  • Acquired: seen in patients with polio and cerebral palsy
  • Associated with arthrogryposis multiplex congenita, myelodysplasia, spina bifida, and maternal cigarette use

Classification

There are multiple classification systems for talipes equinovarus:

  • Dimeglio: measures and scores 4 elements
    1. Equinus in sagittal plane
    2. Varus deviation in frontal plane
    3. Derotation around talus of calcaneo-forefoot (CFF) block 
    4. Adduction of forefoot on hindfoot in horizontal plane
  • Pirani: 6 “signs” scored 0, 0.5, or 1 based on severity
    1. Medial crease
    2. Curved lateral border
    3. Lateral head talus
    4. Posterior crease
    5. Empty heel
    6. Rigid equinus

Clinical presentation

  • Mid- and forefoot are adducted (medially deviated).
  • Equinovarus:
    • Plantar flexion of foot at ankle (equinus): dorsiflexion beyond 90° not possible. 
    • Inversion deformity of heel (varus); hindfoot supinated
  • Calf is smaller at presentation (and will remain smaller throughout life).
  • Generally painless

Talipes equinovarus (clubfoot)
Foot deformity featuring plantar flexion, medial rotation of the forefoot and inward facing sole

Image by Lecturio.

Diagnosis

  • Characteristic deformity is readily identified at birth.
  • Can be detected prenatally by ultrasound

Management

Refer to a pediatric orthopedic surgeon soon after birth for prompt initiation of treatment.

  • Initial: 
    • Manipulation of foot to stretch contracted tissues followed by serial casting (Ponseti method)
    • Correction occurs rapidly if instituted shortly after birth.
  • If equinus remains, surgery may be required:  
    • Percutaneous Achilles tenotomy, to achieve full correction
    • Further surgical correction may be needed if foot is rigid and resistant to correction.
  • Prognosis is excellent if treatment is initiated soon after birth.

Ponseti method
Consecutive splinting with casts made following the Ponseti method allow for gradual correction of talipes equinovarus (clubfoot).

Image by Lecturio.

Complications

  • Persistent limp
    • Due to child learning to walk on side and top of foot
    • Occurs when condition is recognized late or not addressed properly
  • Residual loss of range of motion and strength

Mnemonic for talipes equinovarus of clubfoot

CAVE:

  • Cavus
  • Adductus
  • Varus
  • Equinus

Metatarsus Adductus (Metatarsus Varus)

Definition

Metatarsus adductus is a common congenital foot deformity that presents with adduction, or inward deviation of the forefoot (at the tarsometatarsal joint), with normal hindfoot alignment.

Epidemiology

  • Most common foot deformity in infants
  • Male-to-female ratio: 1:1
  • Up to 50% of cases are bilateral.
  • More common in firstborn children and twins
  • Associated with developmental hip dysplasia and torticollis

Etiology

The exact cause is unknown, although 1 proposed etiology is the mechanical effect of a small uterine space.

Classification

  • Bleck classification by heel bisection: 
    • Normal: heel bisector line through 2nd and 3rd toe interspace
    • Mild: through 3rd toe
    • Moderate: between 3rd and 4th toe web space
    • Severe: through 4th and 5th toe web space
  • Berg classification:
    • Simple
    • Complex
    • Skew foot
    • Serpentine foot (complex skew foot)

Bleck classification of metatarsus adductus by heel bisector method
This method is used for classifying the severity of metatarsus adductus deformity. Normal heel bisector line through the 2nd and 3rd toe web space, mild heel bisector line through the 3rd toe, moderate heel bisector through 3rd and 4th toe web space, and severe heel bisector through the 4th and 5th toe web space.

Image by Lecturio.

Clinical presentation

  • Medial deviation of forefoot at tarsometatarsal joint
  • Normal hindfoot
  • Forefoot can be “stretched” into neutral position.
  • Ankle with normal range of motion
  • Painless

Metatarsus adductus: common congenital foot deformity featuring medial deviation of the forefoot at the tarsometatarsal joint

Image by Lecturio.

Diagnosis

  • Parents notice intoeing in first 1–2 years of life.
  • Can be detected prenatally by ultrasound

Management

  • Benign condition that resolves spontaneously or with nonoperative therapy in most cases before the age of 4
  • Passive stretching or no therapy depending on severity
  • Rigid deformity will require serial casting and evaluation by pediatric orthopedic surgeon.

Prognosis

Prognosis is excellent, if treatment is started early.

Clinical Relevance

The following conditions may accompany talipes equinovarus and metatarsus adductus:

  • Developmental hip dysplasia (DHD): congenital orthopedic condition characterized by abnormal development of acetabulum due to luxation of femoral head from hip joint. Developmental hip dysplasia has been associated with talipes equinovarus and metatarsus adductus; therefore, careful hip examination is essential in these patients.
  • Intoeing: sometimes referred to as being “pigeon-toed”; a medial rotational variation where feet or toes point toward the midline during gait. Most common causes are metatarsus adductus of foot, femoral anteversion of hip, and tibial torsion. Intoeing that is painful, associated with limb length discrepancy, and associated with delayed developmental milestones (possible cerebral palsy) or a family history of skeletal dysplasias requires further workup and orthopedic evaluation.

References

  1. Winell, J. J., & Davidson, R. S. (2020). The foot and toes. In R. M. Kliegman MD, J. W. St Geme MD, N. J. Blum MD, Shah, Samir S., MD, MSCE, Tasker, Robert C., MBBS, MD & Wilson, Karen M., MD, MPH (Eds.), Nelson textbook of pediatrics. Retrieved January 29, 2021, from https://www.clinicalkey.es/#!/content/3-s2.0-B9780323529501006945
  2. Green, A., M.D. (2020). The pediatric foot and ankle. Pediatric Clinics of North America, 67(1), 169-183. doi:http://dx.doi.org/10.1016/j.pcl.2019.09.007
  3. Ricco, A. I., Richards, B. S., & Herring, J. A. (2014). Disorders of the foot. In J. A. Herring MD (Ed.), Tachdjian’s pediatric orthopaedics (pp. 761-883). Retrieved January 19, 2021, from https://www.clinicalkey.es/#!/content/3-s2.0-B9781437715491000234

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